Doctors as dealers: Australia's opioid habit

In the last few years prescriptions of opioids for chronic pain have skyrocketed creating a new wave of drug addicts. There's little evidence to support their long term use but doctors are facilitating addictions that can last for years. Ann Arnold investigates Australia's new drug war.

Australia has been warned to stand by for a new wave of heroin use.

Doctors are more and more becoming de facto dealers, and I don't think any of us want that.

Dr Rodger Brough

The FBI and the Drug Enforcement Agency in the US have told the Australian Crime Commission that an escalation of heroin availability and use has taken their country by surprise.

Chris Dawson, a former West Australian deputy commissioner of police, is the new CEO of the Australian Crime Commission. He started in April and could be in for an interesting ride.

‘There’s a large increase in heroin use now in USA, and both the administrator of the DEA and the FBI director, both were advising me, “Look, watch out. There’s a trend there that we’ve seen happen in the States which we would expect would come to Australia",' says Dawson.

Australia is experiencing a mini version of the American epidemic of prescription opioid abuse, obtained mostly through doctors: Oxycontin, Endone and Targin are some of the better known brands.

Now, though, it seems American prescription drug abusers are switching to heroin.

‘What I’m advised by the DEA and FBI is that users are migrating from those lawfully produced substances which have been misused, into the illegal market,’ says Dawson.

He says the Australian Crime Commission is now preparing itself for a scaling up of the heroin trade in Australia.

‘More frankly, I’m advised by our international partners that because of the prices, particularly in Australia, that users are paying for drugs, it’s a very ready market.’

If heroin makes a big comeback, its use will have come full circle. Until a recent stint in jail, Darren was an Oxycontin user and dealer in Warrnambool, on the Victorian west coast. Before that, he was a heroin user.

'When the heroin drought come around in about ‘99, 2000, I got on methadone a bit before that and I had a mate who come around and said, "Here try these OxyContin"," says Darren.

'Geez it was the best thing since sliced bread, I thought. I thought it was great.'

Darren was known as the 'Oxy King of Warrnambool'. He has spent over a decade scamming the medical system to acquire his drugs.

His suppliers were older pensioner neighbours, a woman who was getting bulk supplies from a doctor in Melbourne, as well as a mate who could write a convincing doctor’s letter. Together, the pair would drive around the towns of Victoria’s southwest.

‘He was really good at like bodgin’ up letters and that,’ says Darren. ‘In the phone book he’d get the doctor's name and he'd write it from another doctor that he was moving into the area. He needs to continue his medication and that.’

It didn’t always work, but mostly it did. It helped that his friend, not a drug abuser—‘he was just addicted to money’—was obese.

‘This bloke was like 23 stone, he was a big boy. You know, you look at someone 23 stone and he’s hobbling along and that, he’s obviously in pain.’

This article represents part of a larger Background Briefing investigation. Listen to Ann Arnold's full report on Sunday at 8.05 am or use the podcast links above after broadcast.

It’s not only injecting drug users like Darren who become dependent on prescription opioids. The majority of users begin because of serious pain, and swallow the pills rather than injecting them.

Doctors find it hard to say no because of inexperience with addictive drugs, or discomfort with raising the issue of addiction.

Australia’s opioid prescriptions have tripled over the past 10 years. The escalating use has exposed gaps in the health system; doctors are under-trained to deal with patients demanding pills for their pain, and there’s a shortage of both pain and addiction specialists.

‘Doctors are more and more becoming de facto dealers, and I don't think any of us want that,’ says Dr Rodger Brough, a veteran addiction doctor in rural Victoria.

‘Prescription drug abuse is an enormous problem and it's a problem that more easily passes under the radar, because it doesn't involve anything like the same extent of commotion, emergency departments, ambulance and police chaos,’ says Dr Brough.

In the US, Oxycontin has been the market leader. Four years ago a new version that’s much harder to inject was introduced. It arrived in Australia in April this year.

Since its introduction to the US, there has been a shift to other prescription opioids and, increasingly, to heroin. More broadly, the nation’s addiction to opiate painkillers has created a ready market for heroin, the Australian Crime Commission has been told. The poppies are being grown in Mexico.

‘I’m in receipt of warnings and intelligence products from the USA authorities saying this is more than likely to come your way,’ says Dawson. ‘And we are seeing already the apprehension of Mexicans in the drug distribution in Australia.'

Transcript

Ann Arnold: It's one of Australia's biggest drug problems. This one is facilitated by doctors.

Darren: Off one doctor he was getting four boxes of 80s, three boxes of 40s and two boxes of 20s, a month. And they'd only last us, geez, a week, if that. Then we'd be on to the other doctor in Hamilton, you'd get nearly the same there. And then we'd move onto Portland.

Ann Arnold: Long-term addicts like Darren have made painkillers, particularly OxyContin, their drug of choice for injecting.

Rodger Brough: Doctors are more and more becoming de facto dealers, and I don't think any of us want that.

Ann Arnold: Most people on prescription opioids, usually prescribed for pain, are swallowing them. Prescription rates of the opioid oxycodone have tripled over the last ten years.

Rodger Brough: I think it is getting to the situation where doctors feel so harassed by people requesting opioids for chronic pain problems and their training does not equip them to adequately differentiate patients.

Ann Arnold: People are demanding a pill for their pain, and doctors struggle with saying no, and with identifying who has a legitimate need.

If you had to make a call on what is the biggest public health problem at the moment, ice (crystal meth) or prescription drug abuse, what would you say?

Rodger Brough: Without a doubt it's the prescription drug abuse. It's an enormous problem and it's a problem that more easily passes under the radar because it doesn't involve anything like the same extent a whole lot of commotion, involvement of police, ambulance, emergency departments in chaos, et cetera.

Ann Arnold: In Victoria, more people died from overdoses involving pharmaceutical drugs than died on the roads last year. The majority involved opioids. The escalation in prescription opioid use is exposing gaps in our medical system; under-trained doctors, ill-equipped to prescribe and manage that sort of drug usage, and a shortage of pain and addiction specialists.

At the same time, some health professionals are overtly flouting the rules. Up to 40 doctors and pharmacists in New South Wales are currently being investigated for inappropriately prescribing and dispensing opioids.

But in the main, doctors are unwittingly creating addicts. While opioids are deemed important for acute pain for short periods, they are frequently given for chronic pain over long periods. But there's no strong medical evidence for that.

Three years ago Dan Hogan was prescribed OxyContin and Endone after an accident. He has vivid memories of painful withdrawals.

Dan Hogan: I can remember one occasion I was coming back from Birchip in northern Victoria and I'd run out of prescription, it was two or three o'clock in the morning I suppose.

Ann Arnold: When Dan ran out of his opioids he'd been on them for over a year. He'd been prescribed the drugs after having his foot amputated, but his dependence on them had got out of hand. Dan was driving back to Sydney, and ended up lying on the ground on the side of the road somewhere near West Wyalong, he thinks. He'd had to pull over, in desperation.

Dan Hogan: I just laid next to the car and had a…well, just had to rest for a while. There was nothing I could do. Withdrawal from the opiates when it's cold turkey like that is quite an intense experience. It's both the pain component of it but there's also I think a little bit of an emotional component.

Ann Arnold: So you couldn't drive because you couldn't think straight?

Dan Hogan: Yeah, I was in too much pain.

Ann Arnold: While Dan Hogan took his pills with a glass of water, others, like Darren, would crush them and inject them. Over the past decade, injecting users have increasingly turned to OxyContin.

Darren: When the heroin drought come around in about '99/2000, there was that heroin drought. I got on methadone a bit before that and I had a mate who come around and he goes, 'Here, try these, OxyContin.' Geez, it was the best thing since sliced bread, I thought. I thought it was great.

Ann Arnold: Better than heroin.

Darren: Better than heroin.

Ann Arnold: Darren developed a chronic addiction to OxyContin. As a dealer, he was known as the Oxy King of Warrnambool, on the western coast of Victoria. He's just come out of jail and is trying to stay out of trouble.

Increasing numbers of people are dying from opioid overdose. In 2008, 70% of accidental overdoses were due to pharmaceutical opioids. Authorities are scrambling to deal with the problem. The fear is that we could emulate the North American epidemic of addiction.

Journalist [archival]: On Monday the FDA revealed a new program to fight the misuse of OxyContin and other powerful painkillers. They are blamed for thousands of fatal overdoses every year in the United States.

Ann Arnold: Now, in both the US and Australia, new threats are emerging. In the US, the prescription opioid addiction is leading to a resurgence in heroin use. That's got the Australian Crime Commission worried. CEO Chris Dawson has told Background Briefing about warnings from America's Drug Enforcement Agency, and the FBI.

Chris Dawson: There's a large increase in heroin use now in USA, and both the administrator of the DEA and the FBI director were both advising me, 'Look, watch out. There's a trend there that we've seen happen in the States which we would expect it will come to Australia.'

Ann Arnold: It's a clear shift, he was told, from OxyContin and other prescription opioids, to heroin.

Chris Dawson: What I'm advised by the DEA and FBI is that users are migrating from those lawfully produced substances which have been misused, into the illegal market.

Ann Arnold: So you're now watching out that the Australian Crime Commission is now preparing itself for a scaling up of the heroin trade in Australia.

Chris Dawson: Yes, and more frankly, I'm advised by our international partners that because of the prices, particularly in Australia, that users are paying for drugs in Australia, it's a very ready market.

Ann Arnold: The Australian Crime Commission's Chris Dawson.

Many prescription opioid users, however, didn't go seeking them in the first place.

Three years ago Dan Hogan was developing a renewable energy generator in his home garage in Sydney, when the five-tonne machine fell on him.

Dan Hogan: It was about 20 centimetres above ground level, and when I was lowering it the supports collapsed and it landed on my foot and pinned me against the wall.

Ann Arnold: Dan was able to get his phone out of his top pocket. His wife Lu was at work, but reached Dan before the ambulance.

Lu Hogan: He'd actually been able to dial triple-0, and he told them where he was and that he was pinned under this machine. And he must've been able to also give them my phone number because the ambulance rang me and I went straight back home and found him pinned against the wall with his leg…foot and part of his leg under the machine.

Dan Hogan: Thank God I was able to take a piece of metal out that was crushing my lungs, dial triple-0, then the ambos and the police came. They administered a little bit of morphine at site but they don't like to sedate the patient too much because they need a pain response and they need to keep us fairly active. Then they had to rig up a lot of equipment to pull the machine off my foot because it was so heavy and it was in a confined space, so it was quite complex, it took a couple of hours to cut me out.

Ann Arnold: Dan Hogan's foot was amputated. He had about ten days in hospital, then went to the Ryde Rehabilitation Centre.

Lu Hogan: He probably spent only about a week at Ryde rehab and then became an outpatient because we lived quite close. All during that time he was on very high doses of both Endone and OxyContin.

Ann Arnold: And what was the effect of that, in your observation?

Lu Hogan: Oh he was totally stoned, for months.

Ann Arnold: And how did he function then?

Lu Hogan: Well, it's hard to separate the effect of the drugs from the injury. But he was obviously heavily sedated by the pain relief that he was taking but he was also in significant amounts of pain as you can imagine, having had an amputation, and not really aware of what was going on around him at all.

Ann Arnold: And how dependent was he on that medication

Lu Hogan: Oh completely, and there's no doubt that people who receive a serious injury like that need high levels of seriously good pain relief. You know, they're in significant, significant pain.

Dan Hogan: However, one can't be dependent on opiates all one's life, so there's a stage where you have to reduce opiates, which is the normal practice. And that coupled with the breaking in of the new leg and the nerves having to establish new pathways, whatever, is quite a complex time.

Ann Arnold: With the help of doctors, Dan was able to get his OxyContin and Endone use down. But he couldn't take the next step, and remained on those drugs for a year and a half. Lu Hogan didn't like what that did.

Lu Hogan: I imagine…I don't know, but I imagine it's similar to being addicted to heroin. There are behavioural changes, people are very introverted. When they don't get the medication that they are addicted to, their behaviour becomes very erratic and they're very stressed. So that's fairly unpleasant for everybody. I'd liken it to hanging off a cliff by your fingernails when you're waiting for that next dose of medication.

Ann Arnold: Lu was getting increasingly frustrated.

Lu Hogan: I just kept saying why can't a GP change you to an alternative medication that's not addictive so that you can kick this addiction. And the answer was either 'I don't have the authority or the confidence to make that change in your medication, you need to see a pain specialist'. But the problem is there's just not enough of those specialists around for the number of people that are taking these drugs.

Ann Arnold: Dan Hogan waited months to get into a pain clinic. And as long as some doctors feel under-equipped to manage patients on addictive drugs, or unaware of the risks, they will be effectively feeding drug habits.

Daniel: Hello, I'm Daniel.

Ann Arnold: What's your story Daniel?

Daniel: Well, basically for years I was addicted to opiates and benzos. I've tried just about every pill and every drug there is to try I guess.

Ann Arnold: Daniel is in his 30s, and lives in regional Victoria. His first serious addiction was to morphine, which he was prescribed in bulk after a motorbike accident 16 years ago, in the Northern Territory.

Daniel has worked hard to get himself off drugs, and now has a fulltime job. But the day before we met, he'd spent six hours in a hospital emergency department because he'd hurt his shoulder at work. He left there with a prescription for Endone, one of the addictive opiates, from a young doctor who he thinks might have been an intern.

And did you ask for it or did they suggest it?

Daniel: No, they suggested it. They asked me if I'd had it before and I said yes and they thought it would be the right thing for me.

Ann Arnold: And did they ask any questions about your history…you know, did you have a history of addiction or anything like that or drug use?

Daniel: No, they didn't, I guess because I've been to emergency previously and it's all on my history there so I guess they just had to look it up and they would have known my history, yeah.

Ann Arnold: And do you reckon they did look it up? Did they say anything that made you think that they were aware of that?

Daniel: No, they didn't at all.

Ann Arnold: Daniel admits he was pretty pleased.

Daniel: Do you know what to tell you the truth, yeah, I was excited, like when I first got the script I thought it was OxyContin. And yeah, I did, I got a little bit excited and it sort of took me back, and then I read the script properly and it was like 'oh, it's only Endone'.

Ann Arnold: OxyContin is available in higher strengths than Endone. But the Endone still took him back to his recent addictive past.

And does it make you feel good generally?

Daniel: Yeah well, last night I was a bit funny. I guess because I hadn't taken it for a while.

Ann Arnold: So what's a bit funny?

Daniel: I think I was a bit stoned, yeah, I was relaxed and…yeah.

Ann Arnold: That's Daniel. He was hopeful that he'd stay off the Endone after his five-day script ran out.

Dr Rodger Brough set up as a GP with a special interest in addiction in Warrnambool in the 1980s. He's still one of the few in rural areas. He's also done a lot of drug and alcohol education for doctors across regional Victoria.

Hospital discharge is one of the key points of danger, Dr Brough says. Apart from giving opioids to high-risk people like Daniel, a major problem is giving people a lot of addictive medication to take home.

Rodger Brough: Prescriptions of analgesic medication when people are discharged from hospital don't have to be full PBS quantities. They can be reduced and a management plan can be sent with the patient to their GPs.

Ann Arnold: And that doesn't happen?

Rodger Brough: Doesn't often happen, no, and they're the sort of things that need to be improved and changed.

Ann Arnold: So people are leaving hospital loaded up with a supply to go home with. You're saying even as they walk out the door they're given more than they need to be.

Ann Arnold: And I've certainly seen scripts of my patients being discharged from the hospital where the patient has obviously spoken to the HMO and has got analgesics that they weren't even prescribed when they were in hospital added to their discharge script. So there needs to be a hospital-based education program around the problems of prescription drug abuse as well, yes.

Ann Arnold: Because of the relative inexperience of some doctors, consumer health advocate Merrilyn Walton argues that not all doctors should be able to prescribe opioids. They should get special authorisation, she says.

Merrilyn Walton: I mean, I think there should be credentialing around prescribing of opioids. GPs do it, not all GPs know about opioids and know the consequences or even how to manage pain. That's why we have specialist pain management clinics now and pain doctors. So I think in the future I can see for a GP to do it, they would be credentialed by their college or there should be a protocol about referral to a pain clinic if they're on it for more than, say, three months or something like that.

Ann Arnold: Now Professor of Medical Education and Patient Safety at Sydney University, Merrilyn Walton was the first New South Wales Health Care Complaints Commissioner.

Merrilyn Walton: I had a spinal fusion from S2 to L1, so it's a very long procedure. And this is a photograph of the metal that's going into the pelvis to stabilise the rods.

Ann Arnold: In recent years, she has privately been going through her own kind of hell.

Merrilyn Walton: And that's a picture of the rods going up to L2. These little boxes are cages and there's one on each side.

Ann Arnold: So those are like metal pegs on rods going up on either side of the spine.

Merrilyn Walton: Yes.

Ann Arnold: Like scaffolding.

Merrilyn Walton: It is, indeed.

Ann Arnold: Merrilyn Walton has been living with extreme pain.

Merrilyn Walton: But before this happened, this operation, my L5 shattered into a lot of pieces, 10 or 11 pieces, and I had an operation to remove them.

Ann Arnold: She is still on OxyContin and occasional Endone, 11 months after her second operation.

Merrilyn Walton: With the OxyContin you usually take it every 12 hours, they recommend take it at the same time every time. And sometimes I've missed it by an hour or two I am on the floor in pain. I can't walk, I can't move, I'm in tears. It's not a withdrawal. It's in my back. It's not headaches, it's not vomiting or sweating. The symptoms are my symptoms.

Ann Arnold: It varies with the individual, whether painkilling opioids help or not. Although Merrilyn Walton says they're still important for her pain control, she worries about addiction, and has started reducing her levels of OxyContin ahead of her doctor's advice.

Merrilyn Walton: Look, I've worried endlessly about addiction, asked the doctors looking after me, they're sick of me saying…they said, look, when you've got pain…and I've never, ever had a high. People tell me…they say, 'How do you feel,' and I say, 'Look, I feel less pain, that's all I feel.' I've never had any experience of addiction, even though I know I must be addicted.

Ann Arnold: Not even mild euphoria and well-being?

Merrilyn Walton: No, never, never at all.

Ann Arnold: So you're confident that you'll be able to get yourself right off it?

Merrilyn Walton: Look, I live day to day, I meditate a lot, I meditate half an hour each day, and I've just recently been able to meditate out of some night pain. So that gives me great confidence that I'll be able to manage with limited medication. I don't think I'll ever be able to be medication free.

Merrilyn Walton: I work in Vietnam and Sulawesi and Bougainville and there is no pain relief whatsoever. So I see patients go home with broken necks, broken backs to die. And I am absolutely amazed. So I think pain relief in our country is a precious, precious commodity, and to see it abused is very upsetting. But to put it in a straitjacket as well, so doctors feel scared at prescribing, is not desirable either.

Ann Arnold: It's getting that balance right, between keeping opioids available where needed but not letting them get out of hand, that is challenging the medical and regulatory authorities.

A National Pharmaceutical Drug Use Framework for Action, released late last year, notes that it's difficult for police to take action against traffickers who claim a legitimate reason for having medicines.

Illegal importation of opioids increased dramatically last year. The Australian Crime Commission says pharmaceutical opioid detections doubled. They were being smuggled in, or ordered online. Most of the opioids, 60%, were OxyContin. But it's not just importation that feeds the black market. Drug abusers are scamming doctors and pharmacists.

Darren: You know, you add up 28 pills in a box of 80s…

Ann Arnold: For Darren, the former Oxy King of Warrnambool, the ultimate prize was 80 milligram OxyContin.

Darren: $80 a pill, what's 28 80s, it'd be $1,280 I think it was. That's not a bad dollar when you're buying them for $300 or $400 a box.

Ann Arnold: Darren got some of his OxyContin from a local woman who travelled to a doctor in Melbourne and returned with bulk supplies.

Darren: That wasn't the only other source I had, I had a couple of elderly people that I was getting it off.

Ann Arnold: How did that work?

Darren: Well, they'd go to the doctor, they'd keep a couple for themselves if they had to have blood tests and that so it would show up in the blood tests. But otherwise I would get the boxes off them rather cheap.

Neighbours where I live, there were two neighbours, I was giving one of them, say, for two boxes of 20s and a box of 40s I was giving him about $800. And to a pensioner that's gold, you know, you've paid all your bills, you haven't got much money left. They're not really taking the tablets as required, so when someone offers you $800 and no names mentioned, mate that's gold to a pensioner.

Ann Arnold: What would they have been telling their doctors?

Darren: They both had legitimate pain, you know, one had a car crash, he had bad legs, he was in pain. But he was just getting Osteo Panadol and that, to try and get through.

Ann Arnold: Darren also had another system, working with a non-drug using friend who could write a good letter. Together, they'd hit the road, visiting doctors in other towns, and returning with a haul of OxyContin.

Darren: Because he was really good at bodging up letters and that. In the phone book he'd get the doctor's name, and he'd write it from another doctor that he was moving into the area, he needs to continue his medication and that. And sometimes he'd miss out but other times…because this bloke was like 23 stone, he's a big boy. You know, you look at someone 23 stone who's hobbling along and that, well, he's obviously in pain.

Ann Arnold: Darren, a former OxyContin dealer and user in Warrnambool, Victoria.

Doctors need to be aware of the multiple ways their patients' medication might be shared, warns Dr Simon Holliday, a specialist in addiction medicine from Taree, on the New South Wales mid north coast.

Simon Holliday: People might say, look, my next door neighbour's got a bad back, so why don't you take some of my blue pills? Or their grandson might be visiting and has a look and finds that there's, you know, grandma's supply of whatever opiate there is and they might help themselves. So we have to be aware that by handing out opiates liberally we're also supplying other people apart from our patients.

Ann Arnold: Even when people are using their own drugs, doctors struggle with conversations with the opioid-addicted. Dr Simon Holliday:

Simon Holliday: It's very threatening for doctors to be able to ease people off, because a patient comes in and the doctor thinks, now, they're starting to have troubles with their opiates, they need to look at a different way of dealing with their pain, a more psychological manner. The patient on the other hand says, 'I've got this nerve, you can see it on the MRI, the disc is pressing right on it, I can feel it going down my leg, you need to give me something for this, you're the doctor, I'm here to have a treatment.' And it's very hard, it's very difficult and patients have very strong opinions about having their opiate medication stopped.

Ann Arnold: A study by Simon Holliday and others, in New South Wales, found that doctors were simply not taking their patients off their opioids.

Simon Holliday: We surveyed 404 New South Wales GPs about their opiate management of chronic pain, and very rarely did any of the GPs terminate their opiates, report terminating their opiates, even in the face of behaviours that were suspicious of addictions.

Ann Arnold: This is what happened to Daniel, the former addict who'd just been handed opiates at the hospital emergency department. He'd been addicted to prescription opiates and benzodiazepines, the minor tranquilizers. For about six years, he said, his GP kept writing scripts. But he concedes he was not an easy patient.

Were you quite demanding of those?

Daniel: Yeah, I was. Basically I just told her, look, if you didn't prescribe them I'll get them off the street anyway, and she ended up prescribing, I got them prescribed to me, yeah.

Ann Arnold: That's a difficult situation for a doctor, isn't it.

Daniel: Yes, I guess it would be, but it wasn't in a threatening way. She didn't have to prescribe me those medications at all.

Ann Arnold: Daniel says that once he decided he wanted to get off the drugs, his GP was happy to help, and directed him to meditation and counselling.

Doctors and pharmacists are sometimes more culpable.

The New South Wales Department of Health has told Background Briefing that six New South Wales doctors and seven pharmacists have been banned from issuing controlled, or Schedule 8, drugs in the last year, because of their handling of opioids. A further 20 investigations are now underway.

A worrying trend, the department says, is doctors and pharmacists issuing large scripts of high dose opioids on private, unsubsidised prescriptions, which, unlike PBS scripts, are generally not seen by Medicare.

Real time prescription monitoring is held up as the answer to the abuse problem. Tasmania is leading the way. Dr Adrian Reynolds is the clinical director of Tasmania's alcohol and drug services. He explains how real time prescription monitoring works.

Adrian Reynolds: When a patient presents to another doctor requesting a prescription, let's say for OxyContin, that doctor can look up that patient's details and see whether they have been dispensed that medication or similar medications, when, the quantities, the doses, and whether there are any alerts on that patient that are live, and that would assist them make a decision.

Ann Arnold: The system also means pharmacists can monitor, and be monitored.

Adrian Reynolds: Similarly pharmacists when they're dispensing these medications can see, 'Mr Smith, I see you had this same medication dispensed just yesterday at another pharmacy. I need to ring your doctor and it's for him to decide whether I dispense this medication to you now.' And then there's a third level of checks. There is an automated system within the department that something untoward is occurring.

It's taking years to get this system rolled out across Australia. One thing it won't capture is whether the person on the prescription is the same person who uses the drugs. In Tasmania, when problems are detected, there are follow-up meetings to discuss individual cases.

OxyContin promotional material: When I started taking oxycodone two months ago it was the first time I had felt normal since my original injury ten years ago. All that time I had suffered greater or lesser extent of pain, and now I feel absolutely normal.

Ann Arnold: America's opioid addiction is largely to OxyContin. Since the 1970s, prescription opioid use has been steadily widening beyond cancer patients and palliative care, to potentially any patient with serious pain. That country now has an epidemic on its hands.

In 2007, Purdue Pharma, the company that sells OxyContin in the US, was prosecuted for misleading doctors and patients about the addictive nature of the drug. The company had to pay $600 million in fines and other payments.

Dr Simon Holliday, the Taree doctor with an addiction specialisation, says sophisticated drug company marketing has driven the increasing use of opiates.

Simon Holliday: They've been preparing large amounts of research and a large amount of guidelines, there've been funding learned colleges to help people become more aware of pain and the importance of treating pain with opiates. And the whole thing has become a perfect storm and that ends up with lots of people being exposed to these drugs and getting many harms from them including the harm of addiction.

Ann Arnold: You co-authored an article for the Australian Family Physician journal, which concluded that the benefits of long term opioid therapy had been overstated and the risks and harms understated.

Simon Holliday: I think the reason that we said that is because almost all the research looking into pharmaceutical opiates and pain is of 12 weeks duration maximum and that is because that's what the United States Food and Drug Administration, FDA, that's what they require for their studies in effectiveness.

Ann Arnold: So there is not, it seems, much evidence for long term effectiveness of opioids, so therefore, for chronic pain. Even the company that sells OxyContin in Australia agrees. Dr Christine Smith is the medical affairs director at Mundipharma.

Do you accept that there's little or no evidence for using OxyContin or any other opioids for chronic pain over a period longer than three months?

Christine Smith: The whole area of pain management is very complex, and in fact there are very little data for just about anything we use for the treatment of chronic pain. So yes, that's true for opioids, but it's also true for paracetamol, and it's also true for paracetamol and codeine. We know that these drugs have a lot of data for use in acute pain, but for use in long-standing moderate to severe chronic pain, the data are very limited.

Ann Arnold: While most people don't remain on opiates, the risk of addiction shouldn't be under-estimated, according to Dr Simon Holliday.

Simon Holliday: In the United States they've found that people who've been on opiates for six months, in a follow-up of five to seven years, two-thirds of them are still on them later. So once people are stuck on them for a length of time, they're very unlikely to come off them.

Ann Arnold: To tackle the problem of injecting OxyContin, Mundipharma released a new formulation, billed as 'tamper resistant', in Australia in April this year. It is still a tablet, but it can't easily be crushed, and its opiate can't easily be extracted for injection.

The Kings Cross injecting centre reports that the numbers of OxyContin injectors have dropped dramatically. But there's evidence that former OxyContin users are shifting to other prescription opioids. The highly potent Fentanyl, which can kill if just a fraction too much is used. And Kapanol and Jurnista, also a very powerful pill, are being injected.

What is now also becoming clear, in both the US and here, is that heroin is back.

Darren: Heroin is starting to come back in now, as well as there's a lot of ice around, and it's sending people batty. I reckon they would have been better off leaving the Oxys the way they were and they wouldn't have all the heroin problems starting to come back now. There's that many people that are taking drives to get heroin and that now that wouldn't worry about it a while ago, you know.

Ann Arnold: Darren's account backs up the intelligence from the US, that with a global opiate addiction established, there's now a shift sideways to heroin.

The Australian Crime Commission's Chris Dawson says that based on the American experience, it's inevitable that heroin will fill any market gaps.

Chris Dawson: While it may start off in a licit substance, they then tend to become dependent on it in many cases, and then when the market shifts and the prices are available, serious and organised crime will use any market forces they can. If they then see that there's a marketplace where they can sell substances such as heroin…once a person is addicted to substances, it won't matter where it comes from.

Ann Arnold: The US has been taken by surprise by the resurgence of heroin. The poppies are being grown in Mexico.

Chris Dawson: So I'm in receipt of warnings and intelligence products from the USA authorities saying this is more than likely to come your way. And we are seeing already the apprehension of Mexicans in the drug distribution in Australia.

Ann Arnold: Mundipharma has been lobbying the medical profession, seeking endorsement of its new safer product, and urging them not to prescribe generic oxycodone.

Dr Simon Holliday, who has campaigned against Australia's seduction by prescription opioids, is concerned that GPs will be given a false sense of confidence about prescribing the new OxyContin. He thinks it's a bit rich that Mundipharma is now critical of the earlier form of oxycodone.

Simon Holliday: Mundipharmaceutical produced an oxycodone identical to that of the generics until about March or April, and now they're saying that this is a readily abusable formulation and not to prescribe that but to use their new formulation, which is not like that bad one that we had before March or April. It just seems totally hypocritical.

Ann Arnold: Mundipharma's Christine Smith says the company has been acting responsibly.

Is it fair to be lobbying the PBS and the TGA and doctors against supporting the generic crushable oxycodone when that becomes available, when Mundipharma, you were selling it yourselves up until April this year?

Christine Smith: We brought it to the market as quickly as we could in Australia, and having done that we simply ask that all manufacturers are required to meet the same standards of abuse deterrence.

Lu Hogan: The other thing that astounded me, having been through this experience, is that the medical profession know that these medications are highly addictive, they know that it's a very difficult process to get people off them after they've recovered or partially recovered from an injury or a wound or surgery or whatever. I'm astounded that with all the money that goes into medical research, that we don't have alternative drugs to these available now so that people don't have to go through this awful period of withdrawal and removing themselves from dependence on opiate based drugs.

Ann Arnold: Dan Hogan has found a drug-free way forward, after having his foot crushed and then amputated in Sydney three years ago. When he eventually got into a pain clinic, it turned his life around. He was temporarily put on a painkiller called gabapentin, which particularly suited the raw nerves from the amputation.

Dan Hogan: Yeah, well, I've been painkiller-free for 12, 18 months I suppose. The gabapentin was good, it helped with the withdrawal from the opiates. It also greatly reduced the activity or pain threshold of the skin nerves. But the meditation was a key component of it. I think at some point if you are to become painkiller-free you've just got to accept somehow and manage and learn to keep your mood stable whilst your pain levels fluctuate, which is a complex task but it's achievable, and you've got to accept responsibility I suppose or control over the pain.

Ann Arnold: And Dan is managing all right with his prosthetic foot as well.

Dan Hogan: You do get used to it in time. It's three years since the wound now and I'm not going too badly. My dancing has suffered but otherwise I'm not too bad!

Credits

Comments (29)

Realityhurts ®:

21 Aug 2014 8:06:12pm

Goodness so an x drugie, one doctor plus results in America means that for certain it is going to happen here in Australa at the same level. Lol seriously talk about gossip across the ocean. Australila's population has increased, our mean age has increased, with increased age and population come (logically) increased illness, medicine use, deaths etc etc. Who is the reporter? Do they really know anything or are they just that a reporter listening to some gossip and making a story out of it? What about the researcher? Where did they get their research? How did they back it up? Did they miulti source it? Where are the links? I do hope that logical smart thinkers take this article for what it is...propaganda.

slide4 ®:

22 Aug 2014 9:13:06am

I agree with your comments on the content of this article. What we now call journalism (with few exceptions) is little more than copy paste. The days of the scathing social commentary, well writhen with a balanced prospective of the subject matter seem to be over in the mainstream media.It has been replaced by hysterical, sexualised, politically correct low quality fear mongering.The main steam media is rapidly loosing its credibility and the alternative media is gaining a far greater audience.Or maybe the majority of the population think it’s more important who is on Australia idol what’s is actually happening in the world around them

pouteria ®:

24 Aug 2014 9:09:59am

When one is in chronic debilitating pain, what exactly is wrong or bad about being addicted to opioides? Its as though the state of being addicted is inherently bad? As if one is a lesser person due to the addiction. Opioides like morphine, heroin can be taken every day of one's life without any adverse effect on internal organs so there is no physical health problems.

Lillacat :

22 Aug 2014 10:31:01am

Can you now produce an equally well researched article on how people living with chronic pain can manage this chronic pain to provide some balance.I realise it may not be as 'sexy' as this article, but it may be helpful.

suzis ®:

possum belle ®:

JayFused ®:

22 Aug 2014 10:47:59am

Lets be very careful about saying we are in a 'drug war' or wanting to start a new one. If you want to learn one thing from America's drug wars, its that its extremely profitable for the Government and detrimental to the community.

the issue is not the drugs. And the war can quickly change focus from the drugs to the people who are taking them. Stopping the drugs will not heal and restore the people who turn to them.

People who take them need patience from the community, mercy and grace. I know what its like.

scottbe ®:

24 Aug 2014 6:49:22pm

There is no War on Drugs. It is a war on people. You are right in my view JayFused.

If the drugs were legalised and regulated it would remove all the horrible stigma and enable government to make and "honest buck" from these drugs instead of via keeping slave labour in prisons and destroying lives in the process.

Lost2 ®:

22 Aug 2014 10:52:33am

Talk about tarring every person who takes opiates with the same brush. Why is it when a select few abuse the system, all others feel the wrath, GP's stop writing scripts because they are scared of being caught up in illegal activities, Genuine pain sufferers who do the right thing are the ones who end up losing their medication, having to go through withdrawals and increased pain because of it. As with any Government subsidised payment, whether it be welfare, health and this case medication, honest people are the victims of the actions of the minority of a few who do the wrong thing.

oboist2 ®:

23 Aug 2014 5:08:04pm

Through past experience, I have to say I agree with you. An interesting thing is that over the time I was on oxycontin for my knee, I was not aware of having osteoporosis in the lower back. No I am off oxycontin and taking anti inflammabilities for that....If I move even slightly the wrong way, it takes days for the pain to settle. For those of us who have to deal with pain, many of the other drugs either dont work or have other unwanted side effects.

olddgeorge ®:

TVR ®:

22 Aug 2014 11:18:05am

Most definitely true - not GPs in most cases though - the main culprits are ED doctors (esp at unsociable hours when a packet of Endone is easier to give than to figure out what is causing the pain) and doctors involved in post surgical care especially our Anaesthetic colleagues who often forget that patients do need to be awake and functional once they leave the hospitals. We GPs are then left to pick up the pieces and try and get patients off the drugs. The hospital based doctors often also have no clue regarding the PBS and State & Territory rules on prescribing these drugs. I have lost count of the number of complaints I have made to hospitals and the number of patients that I have had to wean off these poisons

possum belle ®:

24 Aug 2014 5:06:18pm

TVR - shameful - a GP and you are blaming the ED doctors!

"'Endone' is easier to give than to figure out what is causing the pain."

They're working in an EMERGENCY Department, doctor, under difficult conditions, not helped by the government. Didn't you know that it can take a great deal of time to diagnose the real sources of pain.

Mawson01 ®:

22 Aug 2014 12:43:32pm

I am involved in worker's compensation and I see people with back injuries all the time. I can only say that as soon as a doctor prescribes Endone or Oxycontin, the outcome for the injured worker is dramatically worse. They get addicted, their recovery goes backwards, and they do not return to work. They get accustomed to being the victim, and everyone pays for it.

Not only is it addictive, but it actually increases people's sensitivity to pain, meaning that they then need more pain killers than when the original injury occurred.

The problem then becomes that it is far easier to remain on the drugs then to get off them, even letting aside the fact that they are physically addictive.

It is a vicious cycle.

People with chronic pain should not be using these drugs as it makes them worse in the long term.

oboist2 ®:

23 Aug 2014 5:03:45pm

I have to say, I was put on oxycontin because of a knee that was bone on bone. The pain was so bad, I was crying with pain. Oxycontin took a few days to work ( I refused endone immediately) and I was originally taking 20 mg daily. After the pain receded, my doctor and I gradually reduced the dose, so at the last I was on only 2.5 mg of Targin and then could come totally off. The whole procedure was over a 6 month period. On the higher doses, I could certainly suffer withdrawal if i was late in taking it, but under 10 mg daily, it was more than manageable. its fine to call these poisons, and knock people who prescribe or use them, but in my case, it was a life saver. Other medications tried, did not even come close.

olddgeorge ®:

24 Aug 2014 8:17:06am

So do you live with chronic pain. Have you ever been awake at 3am unable to sleep or find a position that doesnt exacerbate that pain. Does your company pay you to make sure that people are chucked off their workers compensation. I wonder.

scottbe ®:

24 Aug 2014 6:57:36pm

This is a very sad and cynical post Mawson. Could it be that the pain your clients experience is more genuine than you recognise?

You end your post but making a recommendation for Lyrica. Are you knowledgeable on this drug? Are you aware that there are many different causes of pain and that no one drug is suitable or effective for every person with back pain due to differing physiological causes?

Please be careful how you judge your clients. There are many people who have genuine medical causes that are at risk of being locked into desperate poverty if your judgement is incorrect.

Lost2 ®:

25 Aug 2014 10:08:50am

I would be very worried if this was the way Work Cover saw it's clients, anyone who works with in pain clinics knows, as do patients, pain is poorly understood, the cause as well as control of pain has no simple treatment, everyone experiences pain differently, they also react to medications differently, that's what makes treating chronic pain so hard. Lyrica is not the wonder drug you make it out to be, most patients report brain fog or memory loss, another is the weight gain, and for some they can't take it full stop. This attitude from Work Cover is why so many end up living a life on a Disability Pension, a one size fits all approach to chronic pain doesn't work, and proven to not work.

olddgeorge ®:

24 Aug 2014 7:55:00am

The moral minority really have captured the ABC. I spent one morning earlier this year arguing the toss with the guests on Life Matters about pain relief and pain services. It seems that any doctor who wants to put their hand up and become a celebrity gets a jersey. One thing that becomes very clear - none of these so called experts have ever lived with chronic , day in day out pain. Worse they presume that using pain relief is a bad thing and "addiction" is the end of the world. If we don't band together another round of even tighter regulation is on its way!!

Surfgrrrl ®:

24 Aug 2014 2:47:29pm

I do think this might be a problem for a subset of the community - possibly even those who have chronic pain, because the danger with most opioids is that you build both a tolerance and a legitimate reliance. The temptation to continue to up the level is problematic. Overdose both from injected heroin and prescribed medication is a risk.

I agree the story is lacking in detail and reference - but I guess it is a heads up rather that the actual piece. Most worrying for me is why Naloxone was included in the graph - Naloxone is an overdose reversal drug. It is part of harm minimisation and has nothing to do with the story. This fact alone makes me concerned that the author might need to go back to his/her subject matter and do a bit more work.

Anna Furlaxis ®:

25 Aug 2014 3:02:51am

Surfgrrl, the author is quite correct to include oxycodone & naloxone. Otherwise known as Targin, oxycodone/naloxone is a relatively new combination drug that, from my understanding as an RN, aims to achieve the same amount of pain relief as oxycodone alone whilst minimising opioid-induced constipation. From what I have read, this effect is caused by naloxone (as an opioid antagonist) competitively binding to certain receptors in the gut.

scottbe ®:

24 Aug 2014 6:45:32pm

This is not news... This has been the case for decades - especially oxycodone preparations.

Neither is it doctors as dealers. Of course you get the occasional who are desperate for quick money for their own reasons, but generally doctors are obliged to suspend their cynical judgement in order to adequately assess the medical problem.

The cause of this is the illegality of non-prescription drugs.

Drug users will chase the cheapest supply. If oxycodone was dearer it would be less likely to be used as heroin might then be cheaper.

But if heroin and other drugs were legalised and regulated by prescription we could then remove the criminal element and the dishonesty associated with trying to con a doctor!

Expert Patient ®:

25 Aug 2014 3:16:30pm

When are the uneducated & uninformed media organisations & medical professionals going to realise, the increase in opioid prescriptions is more about better pain management being provided and much much less about drug addiction and drug dealers being supplied opioids by doctors.

I'm sure there are a few uneducated & uninformed doctors who do do that but come on people, get real here..

I'm a long term (since 2000) opioid user and all I get from taking 80mgs of morphine every day is much less pain. I have been on the same daily dose for 13 years now and I'm not alone...

Check out the real facts with Pain Australia and the work they are doing to help people in pain get the help they desperately need and deserve.

Long term opioid use for Non Cancer Chronic Pain does work and I'm living proof of that fact.